akistan is currently facing a severe malnutrition crisis, with around half of the children under the age of five being stunted, as revealed by the National Nutrition Survey in 2018 [https://shorturl.at/apyHK]. While three out of the country’s seven administrative units have implemented legislation making wheat fortification mandatory to combat malnutrition, the lack of enforcement has hindered progress in addressing this issue.

The remaining four administrative units, including the largest province, the Punjab, have yet to introduce food fortification laws. Experts say there is an urgent need for fortified foods to bridge nutritional gaps, particularly considering the adverse effects of recent record-high inflation and the 2022 floods. These factors have depleted people’s purchasing power and made it increasingly difficult to afford a balanced diet. Failing to provide fortified food can have severe consequences for public health, especially for vulnerable children.

Importance of fortified food in reducing malnutrition:

According to the World Health Organisation, inadequate or excessive nutrient intake, resulting from nutritional imbalances, can cause malnutrition in individuals.

Under-nutrition appears in four main ways: wasting (low weight-for-height), stunting (low height-for-age), under-weight (low weight-for-age), and micronutrient deficiencies (lack of essential vitamins and minerals for body functions).

Food fortification reduces malnutrition. Wheat flour fortification combats malnutrition by enhancing nutrition through added essential vitamins and minerals during milling. To fortify wheat, essential nutrients are added to wheat flour during the milling process, ensuring that the fortified nutrients are evenly distributed and incorporated into various wheat-based foods.

The WHO recommends large-scale food fortification, including universal salt iodisation and fortification of staple foods like wheat flour, maize flour and rice. It also suggests using micronutrient powders containing iron for point-of-use fortification for infants and young children to combat vitamin and mineral deficiencies effectively.

Malnutrition and stunting in Pakistan:

Pakistan has the double burden of malnutrition, with both under-nutrition and over-nutrition present in its population.

Malnutrition’s consequences, such as reduced labour, healthcare costs, and lower productivity, amount to $7.6 billion (3 percent of GDP) annually in Pakistan, according to a report produced jointly by the United Nations World Food Programme and the government of Pakistan in 2017 [t.ly/s4In].

According to the WFP study, more than 177,000 children in Pakistan die annually before the age of five due to malnutrition, resulting in an estimated loss of future workforce valued at $2.24 billion per year.

Other statistics by National Nutrition Survey 2018 revealed that around 40.2 percent of children under the age of five in Pakistan were affected by stunting, which means that they are shorter than expected for their age. Additionally, 17.7 percent of children are wasted, being too thin, and 28.9 percent are underweight.

According to the NNS 2018, micronutrient deficiencies are prevalent throughout Pakistan, with 49.1 percent of children found to be deficient in iron.

The NNS 2018 has revealed that more than a third (36.9 percent) of households in Pakistan experience food insecurity.

According to the 2022 Global Hunger Index [https://shorturl.at/cuy58], Pakistan is ranked 99th out of 121 countries. With a score of 26.1, Pakistan’s hunger level is classified as “serious.”

Legislation and implementation challenges:

In the past, the government of Pakistan achieved significant success in implementing measures to provide the public with iodised salt and fortified oil and ghee containing Vitamins A and D. These initiatives were successfully implemented and have been sustained.

However, its efforts to enact legislation for food fortification remain incomplete and have not yielded the desired results so far.

Among the seven administrative units in Pakistan – Islamabad Capital Territory (ICT), the Punjab, Sindh, Khyber Pakhtunkhwa (KP), Balochistan, Azad Jammu and Kashmir (AJK) and Gilgit-Baltistan (GB) – only three have adopted legislation for food fortification.

Sindh took the lead and passed Sindh Food Fortification Act, 2021. It was followed by the Balochistan Food Fortification Act of 2021 and the Khyber Pakhtunkhwa Food Fortification Act of 2022.

Despite the legislation, all three provinces have failed to implement the laws.

According to the legislation, all three provinces are required to fortify wheat flour with Vitamin B12, zinc, iron and folic acid at an industrial level or within flour mills.

Factors hindering the food fortification legislation include resistance from the wheat flour industry, political pressures and political stability.

“At present, there is no federal-level legislation. The legislation has been prepared with the support of partners, but it has not been tabled in the assembly. We are waiting for political stability in the country so that the legislation can be presented in the National Assembly and approved,” Dr Khawaja Masuood Ahmed, the national coordinator for Nutrition and National Fortification Alliance at the Ministry of National Health Services, Regulations and Coordination (NHSR&C) tells The News on Sunday.

Dr Ahmed cites the strong influence of the wheat flour industry and the political sensitivity surrounding wheat flour in Pakistan as key factors necessitating special legislation, which is currently pending in the Punjab, the province responsible for 65 percent of wheat flour production and supply to Balochistan and KP provinces.

“As far as the provinces are concerned, we started the legislation in the Punjab in 2019. Unfortunately, due to political changes and issues related to the shortage of wheat and wheat flour, the legislation in the Punjab is still at the level of Law Department,” he says.

Dr Ahmed says that food fortification legislation in three provinces clearly states that the cost of fortification, which amounts to no more than five rupees per 20-kilogram wheat flour bag, will be passed on to the population, community or buyer.

Food fortification initiatives and projects:

Provision of fortified food has largely been facilitated in the country by some international non-governmental organisations.

For instance, Nutrition International, an INGO, and its partners fortify wheat flour and edible oil in Pakistan.

“Through a large-scale initiative, Nutrition International executes a food fortification programme in Pakistan, focusing on enhancing the nutritional content of wheat flour and edible oil,” Hafeezullah Ghambhir, the provincial programme manager for Sindh Wheat Flour Fortification Programme tells The News on Sunday.

“During the initial phase of the wheat fortification project (between 2016 and 2020), Nutrition International supplied 2,333 complimentary micro feeder mixer machines to 1,000 flour mills throughout Pakistan, enabling them to blend pre-mix powder to fortify wheat flour. Additionally, subsidised and complimentary pre-mix powder was provided. Nonetheless, the number of flour mills in Sindh incorporating pre-mix powder has significantly decreased from 131 to 20 since the discontinuation of complimentary pre-mix powder,” Ghambhir says.

The provision of fortified food is crucial due to the prevalence of insufficient levels of vital micronutrients like iron, folic acid, Vitamin A, and Vitamin D in more than half of women and children in Pakistan. Insufficient nutrition and deficiencies in essential micronutrients during childhood significantly impact immunity, growth and cognitive development, he adds.

Fortification amid inflation and floods losses:

Inflation is expected to reach new peaks. It is projected to surpass the record-high 37 percent in May, exceeding the recorded rate of 36.4 percent in April.

On the other hand, the areas affected by the 2022 flood have witnessed a rise in malnutrition, particularly among children and women. Limited incomes, coupled with the unavailability of regular food items due to crop and animal losses have contributed to an increase in malnutrition rates in these regions.

Experts say inflation impacts poverty and purchasing power, making it difficult for people to afford a diverse diet, including proteins, dairy, vegetables, fruits, nuts and oils. Interventions like fortification are crucial until affordability improves.

“We know that there is a lot of poverty in Pakistan. Many people cannot afford a lot of things like proteins in the form of different meats, whether it is red meat or fish or poultry. They are unable to afford dairy products and fruits and vegetables. These deficiencies are rising from not having these food groups. These need to be complemented in the form of supplementations,” Dr Ahmed adds.

Dr Ahmed says arrangements should be made for providing micronutrient supplements to children between the ages of 6 and 23 months. Additionally, weekly folic acid tablets should be provided to adolescent girls aged 10-19 years. Women of reproductive age should also be given the necessary micronutrient supplements.

“If people in these age groups are already malnourished, then they need another form of intervention which is specialised nutritious food that has to be given to them so that they grow healthy and are not stunted. When mothers are well nourished they do not bear underweight children that end up with stunting,” Dr Ahmed says.

“Implementing fortification on a large scale is vital. It provides a cost-effective approach to ensuring a well-balanced diet for the general population,” says Dr Fatima Saad, a Karachi-based certified nutritionist working at Nutrition International. Nutrition International is an international non-governmental organisation (INGO) operating in Pakistan, enforcing fortification allows for the inclusion of essential nutrients in grains, specifically benefiting children who require dietary diversity for their growth and development.

Lawmakers like Rana Hamir Singh, a member of the Sindh Assembly and chairperson of the Standing Committee on Food in the Sindh Assembly, admit that there has been a delay in the implementation of the food fortification law in the province.

“Sindh was the first province to pass this law. However, we need to go further to make the rules and regulations. We are initiating the rules and regulations task next week,” Singh tells The News on Sunday.

According to the lawmaker, inflation and floods may have contributed to the rise in malnutrition and stunting cases, but the primary factor is the increasing population. He says it is essential to address population growth in order to effectively reduce malnutrition and stunting cases.

“I belong to the Umerkot district in Thar desert. It has produced bumper crops of bajra (pearl millet) and jowar (Sorghum) this season. Despite that, if malnutrition continues in my area, then it means that the problem is not a lack of food, but behaviours,” Singh adds.

Missing link:

According to a document published by the National Initiative for Sustainable Development Goals (SDGs) [https://www.sdgpakistan.pk/web/goals/goal2] - a project of the government of Pakistan to institutionalise the 2030 agenda for sustainable development - the country is committed to ensuring year-round access to sufficient and nutritious food, with special emphasis on children.

Considering the challenges posed by climate change and the expanding global population, projections from the Food and Agriculture Organisation (FAO) [t.ly/JYA6] indicate that feeding a population of 9.1 billion by 2050 would require a 70 percent increase in food production (compared to 2005-07 levels), with developing countries needing to nearly double their production.

Experts recognise the significant contribution of bio-fortification in addressing malnutrition. Its absence from the food fortification laws passed by the provinces in Pakistan is a missing link in the comprehensive approach needed to achieve zero hunger and address malnutrition effectively.

Bio-fortification has the potential to improve productivity by addressing nutrient deficiencies in crops. Experts say in parts of Sindh, the soil lacks zinc and iron, which are crucial for wheat growth.

“Despite cultivating wheat and other grains, our lands lack zinc and iron, highlighting the need for bio-fortification,” Dr Liaquat Ali Bhutto, a director at Sindh’s Agriculture Research Centre at Tandojam, tells The News on Sunday.

According to Dr Bhutto, it is essential to assess the micronutrient content of new wheat seed varieties in relation to the requirement, as deficiencies necessitate bio-fortification.

Contrary to previous beliefs that bio-fortified seeds yield only half as much as traditional seeds, the Agriculture Research Centre (ARC) in Tandojam, Sindh, claims that by implementing bio-fortification, they have successfully developed high yield wheat and rice seed varieties.

“ Sindh produces 35 maunds (one maund is equal to 40 kilograms) of wheat or rice per acre through traditional seeds. However, we have been able to produce wheat and rice seeds through bio-fortification, which results in around 80 maunds per acre yield,” Dr Bhutto claims.

“There are possibly two reasons for not attracting growers to bio-fortified varieties: cost of wheat seed increases to Rs 3,000 rupees per acre; and the credit system where local growers borrow seed from local dealers and repay the loan after the harvest,“ he adds.

According to Ghambhir, currently, the food fortification laws in Pakistan lack the inclusion of bio-fortification, an essential component alongside industrial and domestic fortification.

“Bio-fortification is a missing link in Pakistan’s food fortification laws. Making bio-fortification mandatory through legislation would be instrumental in reducing malnutrition and ultimately advancing the goal of zero hunger,” Ghambhir adds.

Among solutions to prevent the risk of malnutrition, food fortification is generally recognised as a sustainable long-term approach that is easy to implement. Promoting nutritional solutions to ensure nutrient adequacy for children’s development is key.

Fortified children’s nutrition solutions, including complementary food and dairy solutions, offer new hope for helping address iron deficiency.

Massey University in New Zealand has come up with a new and improved iron source (known as Iron+) which offers three times more absorption in body than the existing best available source of iron.

It is imperative that children be given good sources of iron, e.g., organ meat and dark green leafy vegetables etc and products fortified with iron.

Promoting nutritional solutions to ensure nutrient adequacy for children’s development is key.

Fortified dairy products and fortified nutrition solutions (like complementary food for early childhood) can be an effective vehicle for fortification that can improve nutritional quality of diets and thus support normal healthy growth and development in children.

The writer is a Karachi-based freelance environment journalist. He tweets @zulfiqarkunbhar